Long-term Outcome of Laparoscopic Surgery for Nonpalpable Undescended Testis.

Aims and Objectives: The aim of this study was to objectively assess the long-term results of laparoscopic orchidopexy in patients who were diagnosed clinically to have nonpalpable undescended testis (UDT). Materials and Methods: All operated cases of nonpalpable UDT from January, 2000, to January, 2014, were reviewed. After informed consent, all patients were subjected to a color Doppler ultrasound examination to assess the location of the testis, its size, blood supply, and consistency. The size of the testis, operated and nonoperated, was noted down in volume using the formula of 0.71 × length × breath × height. Results: A total of 114 patients could be identified, who had undergone laparoscopy for nonpalpable UDT in the study period. Of these, 44 patients (54 units) underwent a color Doppler study to assess the testes. All the testes were found to lie in the scrotum with preserved blood supply. The volume of the operated unilateral testes (mean = 1.605 cm3) was smaller than the normal nonoperated side (mean = 2.524 cm3). The smaller testicular volume was observed in spite of maintained blood supply to the testes. In cases of bilateral UDT, both the testes were smaller in size (mean = 2.2 cm3), but were comparable to each other. In addition, the ultrasound examination revealed the presence of normal homogenous parenchyma of all the testes similar to the nonoperated side. Conclusion: Laparoscopic orchidopexy is a safe and effective option in the treatment of nonpalpable UDT. On a long-term basis, it is possible to achieve scrotal position along with preserved blood flow following laparoscopic orchidopexy in all patients suffering from nonpalpable UDT.

'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair. MATERIAL AND METHODS: After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator. RESULTS: Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed. CONCLUSIONS: Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

Is Routine Excision of Dysplastic Testicular Remnants/Nubbins Associated with Nonpalpable Testis Necessary? Is Routine Fixation of Contralateral Solitary Testis Indicated? A Survey on the Prevalent Practice among Indian Pediatric Surgeons.

Background and Aims: Dysplastic nubbin also referred to as testicular regression syndrome (TRS) is found in 5% of cases of the Non palpable testis (NPT). There is no consensus on the excision of the above and fixation of the contralateral solitary testis. We aimed to survey the prevalent practice of the same among members of the Indian Association of Pediatric Surgeons (IAPS). Methods: A structured questionnaire was sent through group e-mail and social media platforms to IAPS members to identify their practices in management. Results: A total of 132 surgeons responded to the questionnaire. Excision of intra-abdominal and inguinoscrotal TRS remnants was practiced by 84% (95% confidence interval [CI] 77%-89%) and 82% (95% CI 74%-87%). Fixation of contralateral solitary testis was practiced by 62% (95% CI 53%-70%) in the above scenario. Among the respondents, 30% reported encountering torsion of solitary testis during their career and this experience was a significant factor (P = 0.01) in deciding contralateral orchidopexy. Scrotal infection/necrosis was not encountered by a majority (72%) and it was not a deterrent factor in preventing contralateral orchidopexy (P = 0.68). Conclusions: The majority of pediatric surgeons favored the removal of intra-abdominal/inguinoscrotal TRS remnants identified during laparoscopy for NPT. A majority favored sutureless fixation of the contralateral solitary testis.

Laparoscopic Ladd'S Procedure in Children: Challenges, Results, and Problems.

BACKGROUND: Laparoscopic correction of malrotation in children is challenging. Authors review their experience with indications, results and problems of laparoscopic correction of malrotation. MATERIALS AND METHODS: This is a retrospective study of 41 cases of children who were diagnosed as Intestinal malrotation on clinical and radiological evaluation. RESULTS: Successful laparoscopic Ladd's procedure was accomplished in 35 cases. There were six conversions to open surgery. The mean hospital stay was 4 days (range 3-12days). Restoration of complete feed was achieved on an average of 3 days (range 2-4days). Post-operative recurrence of symptoms was seen in nine cases. Of which, five cases had incomplete correction, three cases had duodenal kinking due to adhesive intestinal obstruction and one had intra luminal duodenal obstruction. All patients underwent open surgery for recurrent symptoms. CONCLUSION: Laparoscopic Ladd's procedure is feasible in children with intestinal malrotation with or without associated volvulus. However, some of them need conversion to open surgery due to difficult local anatomy. For persistent symptoms, they may require redo surgery, which may be due to incomplete correction, adhesive obstruction or intraluminal obstruction.

Laparoscopic repair of Morgagni's hernia: An innovative approach.

AIM: To review our experience of laparoscopic repair of Morgagni's hernia (MH) using transfascial sutures. MATERIALS AND METHODS: This is a retrospective review of patients presenting to the first author with the diagnosis of MH over a 15-year period. The variables analyzed included demographic data, clinical presentation, and operative details. RESULTS: In all there were five male with a median age of 2 years. They were asymptomatic and MH was detected incidentally by observing an air-filled density in the right cardiophrenic angle on plain X-ray of the chest. Computed tomography (CT) confirmed the diagnosis in all patients. All patients underwent laparoscopic repair of MH using transfascial sutures. The average operative time was 75 min. Oral feeding was started 6 h after surgery and patients were discharged on either 3(rd) or 4(th) postoperative day. Postoperative follow-up X-ray confirmed the intact repair. CONCLUSIONS: Laparoscopic repair of MH using transfascial sutures is an easy and effective solution. Multiple horizontal mattress sutures taking full thickness of abdominal wall muscles with the edge of the diaphragm leads to a strong repair. As sutures are tied extracorporeally, the technique is easily reproducible.

Incise, dissect, excise and suture technique of laparoscopic repair of paediatric male inguinal hernia.

BACKGROUND: Authors report incise, dissect, excise and suture (IDES) technique of laparoscopic repair of paediatric male inguinal hernia (LRPMIH). This series retrospectively evaluates a consecutive personal series of children undergoing laparoscopic hernia repair by this new technique. MATERIALS AND METHODS: It is a retrospective review of the LRPMIH done by single surgeon from January 2001 to December 2007. All male patients who were referred to the first author for management of inguinal hernia were given the option of laparoscopic repair. Parents who gave consent for their child to undergo LRPMIH were retrospectively reviewed. RESULTS: A total of 155 patients were operated. Age group was 2 months to 13 years (average-5 years). Follow-up period ranges from 1 to 7 years. Average operating time was 29 min for unilateral and 40 min for bilateral inguinal hernia. Maximum time required was 50 min which was for bilateral inguinal hernia. Bilateral inguinal hernia was present in 10 (6.4%) patients. There were no intraoperative complications. Contralateral processus vaginalis was patent in 25 (16.12%) patients. In the immediate post-operative period 8 patients had port site surgical emphysema which resolved on its own. There are no recurrences so far. One patient developed port site hernia, which was repaired with the standard surgery. There is no incidence of clinical testicular atrophy. CONCLUSION: LRPMIH can be done as routine procedure and also has fewer complications. It has advantage of diagnosing and repairing contra lateral patent processus vaginalis. However a double-blind controlled study is required to establish the results.

Laparoscopic excision of an omental leiomyoma with a giant cystic component.

Primary tumors of the omentum are uncommon, and leiomyomas arising in the omentum are exceedingly rare. We report on a patient who presented with a large abdominal cyst presumed to be an omental cyst. At laparoscopy, after aspiration, the cyst was found to be attached to a solid mass arising from the greater omentum. The entire tumor was successfully excised laparoscopically. Histopathology and immunohistochemistry revealed it to be an omental leiomyoma with a large degenerative cystic component. Treatment by a minimal access approach allowed the patient to recover rapidly with a short convalescence. Our case confirms the feasibility and safety of a minimal access surgical approach to a rare pathological entity.

Superior Mesenteric Artery Syndrome Complicating Spinal Deformity Correction Surgery: A Case Report and Review of the Literature.

CASE: A 13-year-old female presenting with untreated congenital scoliosis underwent single-stage anterior plus posterior deformity correction surgery. On the sixth postoperative day, she started vomiting and complained of abdominal pain. Imaging studies suggested superior mesenteric artery syndrome (SMAS). Conservative treatment for 3 weeks yielded no improvement in symptoms. She subsequently underwent laparoscopic duodenojejunostomy, which resolved her symptoms. CONCLUSIONS: SMAS, although rare, is a morbid complication of deformity correction surgery. Medical management is the treatment of choice, with surgery reserved for nonresponders. Prompt diagnosis and appropriate intervention can provide effective treatment, thus preventing catastrophic consequences.

Airway and esophageal eosinophils in children with severe uncontrolled asthma.

AIM: Children with severe uncontrolled asthma (SUA) have a high burden of symptoms and increased frequency of asthma exacerbations. Reflux esophagitis and eosinophilic esophagitis are important co-morbid factors for SUA. Both are associated with the presence of eosinophils in esophageal mucosa. We hypothesized that esophageal eosinophils are frequently present and correlate with the presence of airway eosinophils in children with SUA. METHOD: We performed a retrospective analysis of a prospective database of children who underwent "triple endoscopy" (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage [BAL] and endobronchial biopsy [EBB], and esophagogastroduodenoscopy with esophageal biopsy [EsB]) at our Aerodigestive Center for evaluation of SUA. Children with known cystic fibrosis, primary ciliary dyskinesia, and aspiration-related lung disease were excluded. RESULT: Twenty-four children (21 males) ages 2-16 years were studied. Elevated BAL eosinophils were found in 10 (42%) patients, endobronchial eosinophils in 16 (67%); 7 (29%) had endobronchial eosinophils without elevated BAL eosinophils. Esophageal eosinophils were found in 11 (46%) patients. There was a correlation between the amount of eosinophils in BAL and EBB (R = 0.43, P = 0.05) airway eosinophils, defined as elevated BAL and/or EBB eosinophils, correlated with esophageal eosinophils (R = 0.41, P = 0.047). CONCLUSION: We concluded that airway and esophageal eosinophils are frequently present in children with SUA.

Video assisted thoracic surgery in children.

Thoracoscopic surgery, i.e., video assisted thoracic surgery (VATS) has been in use in children for last 98 years. Its use initially was restricted to the diagnostic purposes. However, with the improvement in the optics, better understanding of the physiology with CO2 insufflation, better capabilities in achieving the single lung ventilation and newer vessel sealing devices have rapidly expanded the spectrum of the indication of VATS. At present many complex lung resections, excision of mediastinal tumors are performed by VATS in the experienced centre. The VATS has become the standard of care in empyema, lung biopsy, Mediastinal Lymphnode biopsy, repair of diaphragmatic hernia, etc. The article discusses the indications of VATS, techniques to achieve the selective ventilation and surgical steps in the different surgical conditions in children.

Steroid effects on mucociliary clearance in outpatient asthma.

Asthma, a chronic inflammatory condition of airways, responds to therapy with anti-inflammatory medications, for example, inhaled (ICS) and/or systemic (SS) corticosteroids. It is associated with impaired clearance of airway secretions. We studied effects of ICS and SS on mucociliary clearance (MC) in outpatient asthma through an in vivo, randomized, placebo-controlled single blind study with patients acting as their own control. Using a gamma camera and radiolabeled aerosol, we measured MC at baseline, after 4 days of nebulized treatment and after 5 days of oral prednisone. MC was expressed as percent of retained activity over time. Spirometry was performed before each MC study. Treatment with nebulized budesonide did not affect MC or forced expiratory volume at 1 sec (FEV1). Treatment with SS was associated with a significant improvement in MC at 24 h (baseline, 41 +/- 6; post-SS, 36 +/- 5; p = 0.04). Post hoc analysis revealed that MC changed only in those patients with significant changes in deposition (specific Central-to-Peripheral ratio C/P--baseline, 1.57 +/- 0.16; post-SS, 1.73 +/- 0.21; n = 6; p = 0.05), suggesting that the changes in MC were not directly related to therapy. In outpatient asthma, MC is unaffected by 4-5 days of anti-inflammatory therapy in spite of significant changes in FEV1.

A Rare Cause of Chronic Life Threatening Bleeding in a Girl: The Ulcerated Blind Loops.

Ulceration in a blind loop can lead to massive gastrointestinal tract (GIT) bleeding. A 13-year old girl presented with symptomatic melena requiring repeated blood transfusion since childhood. She was an operated case of small bowel atresia in neonatal life. Her upper and lower gastrointestinal endoscopies were normal. Operation showed presence of multiple ulcers in two blind loops (parts of previous side to side anastomosis) and at the anastomotic site. She underwent resection and end-to-end anastomosis of the small bowel leading to complete resolution of melena and anemia.

Transabdominal preperitoneal repair of a port-site incisional hernia.

A 47-year-old woman presented with an incisional hernia at the site of a 10-mm port placed in the left iliac fossa during laparoscopic oopherectomy performed 6 years previously. The hernia was repaired laparoscopically by a transabdominal preperitoneal approach using one 10-mm and two 5-mm ports. Adherent omentum was reduced from the sac and a wide flap of peritoneum extending 5 cm on all sides of the fascial defect was raised. The peritoneum was circumcised around the neck of the sac, leaving the sac undisturbed. A 12 x 12 cm polypropylene mesh was placed in the preperitoneal plane and secured in place with endoscopic spiral tackers. The peritoneal incision was approximated with a running 2-0 polyglactin suture. The patient had an uneventful recovery and was discharged after 48 hours. She resumed normal activity within 5 days and remains well one year later. A transabdominal preperitoneal repair seems a feasible alternative for repair of port-site incisional hernias that usually occur through a single and small fascial defect.

Laparoscopic repair of idiopathic perforation of urinary bladder.

A 45-year-old man presented with a 10-day history of dysuria and abdominal distention. Clinical examination revealed free intraperitoneal fluid and tenderness in the lower abdomen. Hematological and biochemical parameters were normal except blood urea nitrogen of 76 mg/dL and serum creatinine of 3.4 mg/dL. Ultrasonography confirmed moderate ascites with normal-appearing kidneys. In view of high creatinine level, normal kidneys, and acute-onset moderate ascites, urinary ascites was suspected. A micturating cystogram showed extensive intraperitoneal extravasation of the contrast. Cystoscopy identified a 2.5-cm perforation on the right side of the dome of the bladder. A laparoscopic closure of the perforation was carried out in 2 layers. The histopathology of the excised edge showed nonspecific inflammatory changes, and a subsequent urodynamic study was normal. The patient remains well 3 years later. This case highlights the successful use of laparoscopy in the treatment of a rare urological condition and reviews the previously reported cases of laparoscopic closure of bladder perforation.

Laparoscopy-assisted transperitoneal percutaneous nephrolithotomy for recurrent calculus in isthmic calix of horseshoe kidney.

BACKGROUND AND PURPOSE: Management of urolithiasis in a horseshoe kidney (HSK) poses a unique challenge. Although most patients can be managed by a combination of percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (SWL), calculi in the isthmic calix remain difficult to treat, as this area is out of reach during rigid PCNL, and, owing to the poor evacuation of the fragments, the results of SWL are suboptimal. CASE REPORT: A 59-year-old man known to have an HSK presented with right-sided lower-abdominal pain and episodes of urinary infection. In the past, he had undergone pyelolithotomy and lithotripsy for lithiasis in the kidney. Imaging studies identified a large recurrent calculus in the anteriorly directed isthmic calix. This was treated successfully by a laparoscopy-assisted transperitoneal PCNL. The laparoscopic view allowed the bowel to be retracted away from the site of the HSK, and PCNL guided by fluoroscopy and laparoscopy was performed. Complete stone clearance was achieved in a single stage. The patient remains free of symptoms and recurrence 3 months later. CONCLUSION: We believe this to be the first report describing this novel approach to lithiasis in an HSK.

A novel technique for extraction of the appendix in laparoscopic appendectomy.

A new technique for extraction of the appendix by its retrograde introduction into the umbilical port is described. With this technique, appendectomy can be undertaken with a single 10-mm and two 5-mm ports.

Laparoscopic management of antenatally-diagnosed abdominal cysts in newborns.

We report two newborns each detected to have a large intra-abdominal cyst on antenatal ultrasonography. Postnatal imaging confirmed presence of the cysts and showed a complex cyst with multiple septae in the first patient and evidence of bleeding in both. Laparoscopy performed on the 14th and 19th day of life, respectively, showed ovarian cysts with hemorrhage and torsion. The cysts were treated successfully by laparoscopic oopherectomy. Histopathology revealed an ovarian gonadoblastoma in the first patient and a simple cyst with calcification in the second. Both patients remain well at a follow up of six and four months. Laparoscopic treatment of antenatally detected cystic abdominal masses is a feasible option in the newborn.

Prevention and management of complications of laparoscopic splenectomy.

Laparoscopic splenectomy (LS) has become a commonly performed minimal-access operation. With increasing experience, surgeons are undertaking LS for multiple pathologies and tackling spleens of diverse sizes. LS remains a challenging procedure to be performed by experienced laparoscopic surgeons, well supported by a team. Bleeding remains the commonest intraoperative complication and perhaps the commonest reason for conversion to a laparotomy. Although the incidence of postoperative complications following LS is lower than that after open splenectomy, thrombosis of the splenoportal axis is being increasingly recognised. The present review describes both the common as well as uncommon intraoperative and postoperative complications of LS and outlines measures to be taken for their prevention and management.